CEO SUMMARY: When the American Clinical Laboratory Association filed its lawsuit Dec. 11 against the Secretary of Health and Human Services, one of its main claims is that HHS collected payment data on the clinical laboratory testing business in a manner that was deeply flawed. HHS then used that flawed data to set payment rates
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Healthcare Common Procedure Coding System (HCPCS) codes are a set of health care procedure codes. Standardized code sets are necessary for Medicare and other health insurance providers to provide healthcare claims that are managed consistently and in an orderly manner. HCPCS was established in 1978 as a way to standardize identification of medical services, supplies and equipment.
HCPCS codes were developed to simplify medical billing. Standardized coding is necessary to ensure that claims processing proceeds in an organized and uniform way. HCPCS codes are used by both public and private health plans. Originally, use of the HCPCS codes was voluntary, but after Congress passed the Health Insurance Portability and Accountability Act (HIPAA) in 1996, requiring that the Center for Medicaid and Medicare Services (CMS) adopt standards for coding systems for reporting and billing health care transactions, CMS established HPCPS as the coding system that entities covered by HIPAA are to use.
Level 1 HCPCS codes are numeric and are based on the American Medical Association’s Current Procedural Terminology (CPT).
Level 2 codes are alphanumeric and primarily include non-physician services and supplies not covered by Level I codes. This coding system is also used as an official code set for outpatient hospital care, chemotherapy drugs, Medicaid, and other services.
A medical coder, as part of the laboratory billing process, works to abstract and assign the appropriate coding on medical claims. In order to accomplish this, the coder checks a variety of sources within the patient’s medical record (i.e. the transcription of the doctor’s notes, ordered laboratory tests, requested imaging studies and other sources) to verify the work that was done. Then the coder must assign CPT® codes, ICD-9 codes and HCPCS codes to both report the procedures that were performed and to provide the medical biller with the information necessary to process a claim for reimbursement by the appropriate insurance agency.
CEO SUMMARY: At a recent coding and billing conference, pathology and lab clients of one of the nation’s largest revenue management companies agreed that three trends have caused lower revenues since the start of 2014. One trend seen by labs involves higher deductibles and copayments from patients. Another is the exclusion of local labs from
CEO SUMMARY: Once again, the lab industry faces a mixed bag following passage of a new law by Congress last week. Besides the one-year fix for the SGR, H.R. 4302 also has language that may defer adjustments to Medicare Part B lab test fees until 2017 and creates a new procedure for Medicare officials to
CEO SUMMARY: For the clinical lab industry, the concept of competitive bidding for Medicare Part B Clinical Lab Testing may be like the movie “Groundhog Day.” The hero, Bill Murray, kept reliving the same day over and over. So it seems to be with competitive bidding. In the latest replay, RTI Technologies just published a
CEO SUMMARY: For labs currently processing prostate biopsy cases with five or more cores and for those pathologists interpreting those cases, there is a lack of clarity about new Medicare policies. As one example, risk of an audit is significant because of recent guidance issued by one Medicare contractor. Another source of risk for labs
CEO SUMMARY: When Medicare’s National Correct Coding Initiative (NCCI) manual took effect on January 1, 2012, it contained a significant change in how prostate biopsy claims are to be coded. This change was widely overlooked by the pathology profession and even dismissed entirely for its ambiguity and inconsistency with previously published guidance on the subject.
CEO SUMMARY: How will pathology laboratories respond to the publication of revised policies in how laboratories should file Medicare Part B claims for prostate biopsies? Not only will there be a sharp drop in the reimbursement paid for a 12-core prostate biopsy, but labs may be at increased risk of a RAC audit, along with